Особливості патогенезу, клініки, діагностики та лікування ішемічної хвороби серця у жінок залежно від факторів ризику

Ключові слова: ішемічна хвороба серця, статеві відмінності, фактори ризику, клініка, діагностика, лікування, прогнозування.

Summary

O.М.Barna. Peculiarities of pathogenesis, clinical manifestations, diagnostics and treatment of coronary artery disease in women depending on the risk factors/ Manuscript. Dissertation for academic degree of doctor of medical sciences after specialty 14.01.11 - cardiology. National Medical University named by O.O.Bohomolec, Kyiv, 2006.

The solution of scientific and practical problem of modern cardiology - improvement of diagnosis and treatment of coronary artery disease (CAD), based on the complex comparative study of pathogenesis, clinic, diagnosis, treatment and concomitant risk factors (RF) of CAD in women and men - is proposed in the work.

Prospective supervision was conducted during 1 year, and included 457 patients with acute coronary syndrome (ACS), 222 patients with stable angina (SA), and 98 women with surgical and natural menopause. For control were examined: 20 healthy men, 20 healthy premenopausal women and 20 healthy postmenopausal women. The additional analysis of separated patients groups was performed for the decision of other tasks.

Prevalence of non-Q-myocardial infarction (MI) and unstable angina (UA) and frequent hospitalization with the unconfirmed diagnosis of MI in women comparatively to men had been fixed. The rate of death in ACS in women had occurred higher than in men. Recurrent angina and congestive heart failure among survived after ACS patients had been occurred more frequently in women than in men. Recurrent MI in women happens rarely and in more elderly persons, than in men. Survival rate after recurrent MI was in women worse, than in men, most probably because of senior age and high rate of arterial hypertension (AH) and diabetes mellitus (DM). The structure of RF for ACS specifically and CAD in general in women and men was different. In women population the most important are DM, AH, smoking, and special women's RF -- estrogen deficiency.

SA in women occur in later age, and regular RF - AH and DM -- are compromising factors also. In men are typical other RF- chronic obstructive pulmonary diseases, smoking or general atherosclerosis. The clinical manifestation of SA in men and women differs also: in women usually SA appears as breathlessness, rhythm disturbances, and pain with non-typical localization and irradiation.

The important pathogenic mechanism in developing of sex differences of CAD lays in the peculiarities of coagulation in suffering from CAD menopausal women, due to combination of oppositely directed changes of coagulation and anti-coagulation in these two pathologies. Comparatively to men women have higher level of acute inflammatory markers, which are responsible for destabilization of atherosclerosis. In women with CAD have prevalence diastolic LV dysfunction, and more serious general clinical course of SA: senior overage age of patients, later beginning and rapid progress, a great deal of unstable angina and prognostic unfavorable rhythm disturbances, higher heart rate and protracted QT-segment. For multiplying of the prognostic value of signal-averaged ECG sex-corrected criteria of late ventricular potentials are recommended. The ECG-exercise test in women often fails because of underloading and/or results in rhythm disturbances; painless ischemia is infrequent, but in big quota of young women angina pain during the exercise occurs in combination with ischemic changes of ST. Despite this, in young women pseudo-positive results of ECG-exercise test are often.

According to coronaroangiography, quantity of women patients is 4,5 times less than men, and women requiring arteriocoronarography are elder than men. The women's average diameter of coronary vessels is significantly smaller than men's one. One- and two-vessels damage is more often in women, than in men. Normal arteries and coronary spasm are discovered predominantly in women too.

Surgical menopause is also considered to be a special RF, as well as others hypoestrogenic conditions and some cases of hormonal imbalance during a pregnancy. Metabolic and -- later - structural changes in surgical menopause develop quickly, however they response rapidly for drug supplies.

We had established some differences in treatment of CAD in women comparatively to men: unreasonably small use of в-blockers and thrombolytic medications, and smaller than in men use of statins and aspirin. More frequent use of calcium antagonists and metabolic drugs (trimethazidine) is confirmed with their higher activity in woman population.

Based on the conducted single-factor analysis, sex differences in predictors of 1-year unfavorable prognosis for patients with ACS and SA had been determined, and in this ground differential multifactor models of unfavorable prognosis had been developed.

Keywords: coronary artery disease, sex differences, risk factors, clinical presentations, diagnosis, treatment, prediction.

Аннотация

Барна О.Н. Особенности патогенеза, клиники, диагностики и лечения ишемической болезни сердца у женщин в зависимости от факторов риска - Рукопись. Диссертация на соискание научной степени доктора медицинских наук по специальности 14.01.11 - кардиология. Национальный медицинский университет имени А.А.Богомольца, Киев, 2006.

В роботе предложено решение актуальной проблемы кардиологии - улучшения диагностики и лечения ишемической болезни сердца (ИБС) у женщин на основании и проведения комплексного сравнительного изучения патогенеза, клиники, диагностики и лечения ИБС у женщин и мужчин в зависимости от факторов риска. Работа базируется на данных наблюдения и обследования за 457 больными с острым коронарным синдромом (ОКС), 222 - со стабильной стенокардией, 98 женщин с менопаузой.

Продемонстрированы различия в патогенезе ИБС у женщин и мужчин на примере изучения системы гемостаза, липидного обмена и маркеров воспалительного ответа. Подтверждены и детализированы различия клинической картины острых и хронических форм ИБС у мужчин и женщин. Проведено сравнение данных диагностических тестов в ген дерном аспекте при ИБС, на основании чего предложены критерии для повышения диагностической ценности соответствующих методик. Детально изучена роль менопаузы как специфического фактора риска ИБС и предложены методы коррекции климактерических нарушений при наличии ИБС. Изучена частота и эффективность современных методов лечения у женщин. Разработаны дифференцированные многофакторные прогностические модели для мужчин и женщин со стабильной стенокардией и ОКС.

Ключевые слова: ишемическая болезнь сердца, половые различия, факторы риска, клиника, диагностика, лечение, прогнозирование

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